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HomeMy WebLinkAboutBLDP-22-002777 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE November 15,202'PERMIT# BLDP-22-002777 JOBSITE ADDRESS 57 SQUIRREL RUN OWNERS NAME COGNETTA PHILIP J G OWNER ADDRESS COGNETTA BARBARA A P 0 BOX 55 YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED:YES❑ NO FIXTURES FLOORS—. BSM 1 2 3 I 4 5 6 7 8 9 10 11 12 13 14 BOILER _ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOIATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER - ROOM I SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER _ UNVENTED ROOM HEATER _ WATER HEATER 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY El BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that as of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that at plumbing work and installations performed under the permit issued for this application will be in compliance with at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Richard Whiteside LICENSE# 15850 SIGNATURE MP©MGF 0 JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: Murphy Services,Inc. ADDRESS. 34 White's Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5087601660 FAX CELL EMAIL S31ON M3IARI NVld VS #11W2i3d $ �33d 0-4. y 1 7/ !-z(z i ❑ ❑ ±IWb3d 31-11 SV SAM3S NOl1VCllddV SIHl oN saA S31ON NO1103dSNI 1VN13 ,C1NO 3Sl 210103dSNI e103 3OVd SIH1 S310N NO11D3dSNI SVO HDflO